neurosurg 01/22/17 Flashcards
subarachnoid hemorrhage path pres dx tx
-aneurysm leaks or bleeds (usually w some activity that causes berry aneurysm to rupture)
-thunderclap headache (sudden and suddenly maximally intense, “worst headache of life”)
hx of sentinal bleed (if pt awake to tell)… treated symptomatically, went away
neck stiffness
headache - fnd - coma
-non-con head ct (for blood in subarachnoid space, cisterns, sulci, maybe ventricles… not parenchyma)
maybe lp for xanthochromia if noncon head ct neg but still want to ro subarachnoid
-early tx (v48hrs) - dec Bleeding by dec bp v140/90 (bb’s, ccb’s) coil or clip aneurysm, dec Hydrocephalus w serial lp’s or vp shunt… more likely to clip and shunt if opening head w craniotomy to dec pressure when pt really in bad shape… otherwise if no craniotomy prob coil and serial lp’s), try to dec ICP w mannitol or hypertonic saline elevating head of bed and hyperventilation to avoid craniotomy, Seizure ppx (any first line, eg levitiracetam keppra)
-late tx (5-7days) - ppx Vasospasm w ccb’s (nimodipine), tx breakthrough vasospasm by inc bp w vasopressors (not bleeding anymore so strat diff from early tx)
what info does a non-con brain ct give you
blood or no blood
bleed
eg in setting of stroke, subarachnoid hemorrhage, intraparenchymal hemorrhage, epi, subdural hematoma…)
lens shaped dural hematoma is…
epidural
crescent shaped dural hematoma is…
subdural
diagnosed subarachnoid hemorrhage by noncon head ct
next diagnostic step is…
angiography (mr or ct preferred to.. the one where poke skin… unless endovascular maneuvar to treat pending…)
want to rule out subarachnoid hemorrhage despite negative noncon head ct (eg w milder sx.. like bad headache w hx of sentinal bleed… vs massive fnd’s w negative ct definitely not subarachnoid hemorrhage)…
next diagnostic step…
lumbar puncture for xanthochromia (yellow tinged csf from old blood)
how to diff subarachnoid hemorrhage from traumatic tap by lp
csf blood will not clear by tube 4 like traumatic tap will
traumatic tap (some iatrogenic bleeding) may show blood in tube 1 but should be absent by tube 4…
intraparenchymal hemorrhage path pres dx tx
-almost always in setting of htn
-fnd ha n/v
ams coma if rapid progressing and severe
-noncon head ct scan
-dec ICP w mannitol or hypertonic saline elevating head of bed and hyperventilation, craniotomy and evacuation of bleed if necessary
-f/u w ct scans to check if hematoma expanding, will need to evacuate if so (can cross midline, uncal herniation - cn III occ motor palsy psns fixed pupillary dilation first before motor down and out palsy… potential brainstem compression respiratory depression and death…)
describe subarachnoid hemorrhage vs prior sentinel bleed with regard to medication response
subarachnoid - not responsive to morphine
sentinel bleed - able to push through with acetaminophen and ibuprofen
what type of headaches does high flow oxygen treat
cluster headaches
when is cerebral ischemia from vasospasm a risk after subarachnoid hemorrhage
5 days to 6 weeks
bleeding in brain w fnd’s… next step
immediate surgical evacuation
for med student level… some intricacies to not evacuating
what kind of brain bleed can be treated w endovascular repair
subarachnoid hemorrhage
others cannot
when is lumbar puncture the answer in the setting of a brain bleed
ONLY to ro subarachnoid negative on CT
NEVER remove csf from a system w compressive symptoms (inc ICP can cause herniation and death)
“walk, talk, die” syndrome in setting of brain bleed corresponds to what dx
epidural hematoma (w lucid interval) (brisk arterial bleed most often middle meningeal, midline shift and herniation)
pt on coumadin for afib presents w small intraparenchymal hemorrhage on head ct
next step…
ffp
stop the brain bleed, ffp is fastest
(unless already signs of herniation, then choose craniotomy)
fall plus progressive dementia
think…
chronic subacute subdural hematoma
torn bridging veins, elderly
2 presentations of subdural hematomas
super trauma plus loc where pt does not wake up - acute
(mva, shaken baby, big fall)
mild trauma plus no loc w progressive cognitive decline - chronic subacute
(alcoholics and elderly - bridging veins stretched from cortical atrophy easier to shear w minor trauma)
locked in syndrome
define
which artery thrombosed
what does it look like on ct
looks like persistent vegetative state but fully awake aware and conscious
basilar artery
ct is normal
think a guy w sudden fnd’s is having a stroke
next step?
nexts?
head ct - to rule out intracranial hemorrhage
must know if bleed or not bleed or else mismanagement can be fatal
then mri to confirm stroke
carotid us to assess for stenotic lesion
2D echo and ecg telemetry
tPA if no bleed, asa for secondary ppx of stroke
focal neurologic deficit of short duration
next dx test to get
head ct
(will be first step whether infection, mass, bleed, ischemic stroke)
must diff bleed from no bleed before trying to treat
basilar skull fracture
presentation
racoon eyes
ecchymosis below/behind ear
clear otorrhea/rhinorrea (csf out ears or nose)
tf
clear otorrhea/rhinorrhea in setting of trauma is boogers
f
think csf
blood vessel assoc w epidural hematoma
middle meningeal artery
epidural hematoma
pres
dx
tx
super trauma (baseball bat, ski accident)
loc - lucid interval - die (walk talk die syndrome)
-ct scan - lens shaped hematoma
-craniotomy to evacuate hematoma
tf
anyone w head trauma significant enough for loc deserves a ct scan
t
ro bleed
tf
decreasing ICP likely to affect prognosis of acute subdural hematoma
f
do hyperventilate, elevate head of bed to 30deg, give mannitol or hypertonic saline to dec icp
but if pt dying from subdural, prob from parenchymal damage not icp
acute subdural hematoma
pres
dx
tx
young pt (shaken baby, teen w superman syndrome mva or ski)
massive trauma, loc, death
ct scan noncon - crescent shaped hematoma
dec ICP - hyperventilate, elevate head of bed to 30deg, give mannitol or hypertonic saline
but not likely to impact prognosis - if pt dying from subdural, prob from parenchymal damage not icp
concussion
pres
dx
tx
sports trauma - loc - retrograde amnesia (can’t remember the play and some leading up to it..)
- noncon ct scan (mri will prob show swelling, but not necessary, see tx)
- GCS^15 and neg ct - can go home under obs and return if any neuro change (can’t arouse, n/v, fnd, sz, etc…)
- GCSv15 or pos ct - need to be admitted because need for neurosurg possible…
diffuse axonal injury
pres
Angular trauma (spinning etc)
loc - no recovery - coma
noncon ct - gray-white blurring
tx - pray, can try to dec ICP but edema not going to kill them, parenchymal injury will
motor nerve to biceps brachii
musculocutaneous nerve
C5 C6
motor nerve to brachoradialis
radial nerve
C 5 6 7 8 T1
motor nerve to triceps brachii
radial nerve
C 5 6 7 8 T1
(long head may be innervated by axillary nerve C5 C6
motor innervation of quadriceps muscle
femoral nerve
L2 3 4
motor innervation of gastrocs and soleus
tibial nerve (branch of sciatic) L45 S123
Deep tendon reflexes, main spinal nerve roots involved
biceps C56 brachioradialis C6 triceps C7 patellar L4 achilles S1
never dx cancer wo…
tissue
but can sometimes guess pretty well based on risks hx imaging etc
% brain cancer that are mets
and which ones
70%
lung breast gi
then melanoma…
tf
brain cancer metastasizes
f
causes sc and death before it mets usually
describe cancer mets to brain on imaging
multiple lesions at grey-white junction
where vasculature catches cancer and other emboli
presentation of brain cancer
fnd’s
seizure
headache (eg if compression or mass effect… no sensation in brain)
n/v
what about headaches and nausea and vomiting become extra concerning for brain cancer
headache worse lying down at night
progression of nausea an vomiting
GCS
glasgow coma scale 3-15
eye response
-open spontaneously 4, to verbal, to pain, none 1
verbal response
-oriented 5, disoriented, inappropriate, incomprehensible sounds, none 1
motor response
-obeys verbal 6, localizes pain, withdraws, decorticate (flex) above red nuc, decerebrate ext below red nuc, none 1
“crab of death” on head ct
non con blood in csf space, fissures
subarachnoid hemorrhage
difference between shunt and drain
shunt into another part of body
drain/ostomy out of body
opisthion
basion
midpoint posterior foramen magnum opisthion
midoint anterior foramen magnum basion
define chiari malformations
anatomic anomalies of cerebellum, brainstem, craniocervical junction… w downward displacement of cerebellum maybe w lower medulla into spinal canal
- I cerebellar tonsils abnorm shape below foramen magnum
- II (arnold-chiari) vermis and tonsils down, beaked midbrain, spinal myelomeningocele
- III (rare) small posterior fossa w high cervical or occipital omphalociele, w cerebellar stuffs into omphalocele, brainstem down into spinal canal
- IV (obsolete) cerebellar hypoplasia unrelated to other chiari malformations
micro vs macro pituitary adenoma
v^1cm 10mm
name front middle and back of sella turcica
tuberculum sella
sella turcica
dorsum sella
innervation of dura
trigeminal V supretentorial
vagus X infratentorial
think cancer in brain? best test to get
MRI w contrast best
(no contrast w ckd.. so noncon MRI next next best…)
then next CT w con if MRI ci
then CT w/o con last resort
tx primary brain cancer
resection radiation chemo
steroids are palliative
sz ppx (lamotrigine, phenytoin, levetiracetam … general antieplieptics..)
prognosis of primary brain canceer
not good
prolactinoma flyby
sx
dx
- bitemporal hemianopsia, large lesions in men
- amennorrhea, galactorrhea, small lesions in women
- pregnancy test, tsh, prl – mri when prolactin elevated
- dopamine agonists
acromegaly flyby
sx
dx
-kids - gigantism
-adults - heart visceral organs face and hands grow don’t fit right, teeth separate, etc
(the stuff that can grow does grow)
-insulin-like gf, glucose suppression test fails to suppress – get brain mri
craniopharyngioma
pres
dx
tx
- asyx tumor in kids… may get short stature if compressing other ant pit hormones…(functional pan-hypopituitarism, but not actually
- calcification of sella on ct or xr
- resect
most common pituitary tumors to know
prolactinoma (male vs female)
acromegaly (kids vs adults)
craniopharyngioma (kids)
age predilection anterior fossa vs posterior fossa brain tumors
Ant Adults
Post Peds
tumors to know in posterior skull fossa
medulloblastoma
ependymoma
posterior fossa brain tumor 2 ddx pres distinctions tx
- medulloblastoma
ependymoma. .. - ICHTN - n/v kid worse in morning, better when curls up into a ball…
- medulloblastoma highly malignant seeds arachnoid get distal lesions – resect AND radiation
- ependymoma from 4th ventricle, obstructive hydrocephalus (better in fetal position.. repositions tumor for ventricular outflow and decreases ICP )
- resection usually enough w/o chemo.. usually no distal lesions
anterior fossa brain tumor
2 ddx
-meningioma - dural, fnd from mass effect – ct scan (calcified/connected to dura) – resection is curative
(the good one to have)
glioblastoma - parenchyma, highly mitotic, necrotic, eats brain… ring-enhancing lesion or bat’s wing deformity (the Only brain cancer that crosses midline, eats way through… not just mass effect) – dismal prognosis… try to resect
astrocytoma fly/by meded
(adult cancer)
basically glioblastoma but prognosis less dismal
(glioblastoma - parenchyma, highly mitotic, necrotic, eats brain… ring-enhancing lesion or bat’s wing deformity (the Only brain cancer that crosses midline, eats way through… not just mass effect) – dismal prognosis… try to resect)
schwannoma
pres
tx
(adult cancer) n/v hearing loss vertigo tinnitis -resect
early morning headaches progressing projectile vomiting papilledema think... order...
brain tumor (complicated headaches lead away from pseudotumor eg if this were a young female) get MRI
what part of head do CTs have a tough time visualizing
posterior fossa
first test for psudotumor ceribri
ct
ddx 32 yo f inc
pseudotumor
vs
brain tumor
diagnose normal pressure hydrocephalus
lp - elevated opening pressure confirms ICHTN, releif of sx confirms dx
reduce ICP for symptomatic relief while awaiting neurosurgical bx and resection of brain tumor
dexamethasone (choice med)
serial lp’s or vp shunt can also be used
benign intracranial htn
= idiopathic intracranial htn
=psudotumor cerebri
NOT equal to normal pressure hydrocephalus
simply define normal pressure hydrocephalus
pathologically enlarged ventricular size with normal opening pressures on lumbar puncture
sudden onset coma and hypotension following headache w bitemporal hemianopsia in woman who has had headaches, worsening hemianopsia, and amenorrhea suggests…
pituitary apoplexy
(prob pit adenoma (prolactinoma) given amenorrhea… small tumor in females… microadenoma because symptomatic galactorrhea amenorrhea… sx ignored, grew pressed on optic chiasm… outgrew blood supply and died, hemorrhaged, comprised all pituitary – panhypopituitarism of sudden onset, ACTH and TSH lost so Cortisol and T4 lost – no catecholamines no blood pressure vessels can’t be made to constrict
so t w IV DEXamethasone - corticosteroid effect to regain bp (not or reducing ICP here)
tx prolactinoma
dopamine agonists
radiation therapy
resection
tx pituitary apoplexy
IV DEXamethasone - corticosteroid effect to regain bp (not or reducing ICP here)
(e.g prob pit adenoma (prolactinoma), amenorrhea… small tumor in females… microadenoma because symptomatic galactorrhea amenorrhea… sx ignored, grew pressed on optic chiasm… outgrew blood supply and died, hemorrhaged, comprised all pituitary – panhypopituitarism of sudden onset, ACTH and TSH lost so Cortisol and T4 lost – no catecholamines no blood pressure vessels can’t be made to constrict
nasty looking necrotic tumor w ring enhancement that crosses midline
best guess at dx
glioblastoma multiforme most likely
but dx w tissue bx
brain mri in kid w stunted growth think…
craniopharyngioma… look at sella/pit
(asyx tumor in kids… may get short stature if compressing other ant pit hormones…(functional pan-hypopituitarism, but not actually
- calcification of sella on ct or xr
- resect)
meningiomas are cured by..
resection
tf
meningiomais a brain tumor
F
an intracranial tumor but not a brain tumor
meningioma will present w
headaches and seizure
age of menintioma pt
18-30 adult usually
tf
all intracranial caners best dxd w mri
f
eg meningioma dense like bone, ct best
when are iv abx indicated in a ring-enhancing lesion w fnd’s or seizure
when febrile
thinking abscess
primary brain tumors of kids
most commonly
- pituitary craniopharyngioma
- ependymoma
- medulloblastoma
tf
craniopharyngioma generally presents w headache
f
tweenager w limited growth and potentially low prl and tsh
calcified pituitary mass =
craniopharyngioma
cushing reflex
define
pathogenesis
tx
-htn and tachyc from inc ICP from brain mass
cause rogressively worsening fnds inpt
what are plain films of the head useful for…
cranial suture anatomy
paranasal and frontal sinuses
sella turcica
(eg for preop planning)
distinguishing characteristic of cervical vertebrae
transverse foramen
(foramen transversarium)
-for passage of vertebral arteries
types of cervical vertebrae
atlas c1
axis c2
subaxial (typical vertebrae)
x ray use for c-spine
trauma
degeneratie diseaes
the most frequently useful plain film view of spine
cross-table lateral view
-2/3’s spinal pathology can be detected in this view
check to make sure plain film caught the whole c-spine
look for cervical-thoracic junction (c7-t1)
how many cervical vertebrae
7 (8 cervical spinal roots however)
swimmer’s view xr
- what is it
- why do
one arm raised above the head
-to better visualize the lower c-spine in pt w shoulders that obscure cervico-thoracic junction on cross-table lateral view
special xr views of c-spine
-uses
- swimmer’s (to see c-t junction if humerus obscures on cross-table lat)
- open mouth odontoid view (can be done w pt supine)
- flex-ex (flexion-extension, for pt w neck pain but no bony abnorm on standard views, or degenerative dz, intervertebral foramena if root compression suspected)
tf
open mouth odontoid xr can be taken w pt supine
t
distinguishing characteristic of thoracic vertebrae
costal facets
use of thoracic spine plain film
trauma
-fx, subluxation, loss of vertebral body height
(AP and cross table lat can be done w pt supine)
distinguishing features of lumbar vertebrae
LACK costal facets (thoracic) and transverse foramena (cervical)
- small transverse processes
- large spinous processes
how many sacral vertebra
5
fused
sacrum articulates with
L5
ilia
useful views of lumbosacral spine
ap - trauma, fx/sublux (can be done supine on backboard)
lat
flex-ex - ligamentous injury - spondylolisthesis
oblique - spondylolysis (pars interarticularis fx or congenital defect)
use of CT in neurosurg
acute lesions
- intracranial hemorrhage, fx, edema, mass lesions (mass effect), hydrocephalus, infarction
- –or per meded “bleed or no bleed”
use of angioplasty in neurosurg
diangostic and therapeutic uses
- coils, balloons, eg for cerebral aneurysms, and w surgery and radiosurgery of avm’s
- superselective intra-arterial papaverine or balloon angioplasty eg for cerebral vasospasm after subarachnoid hemorrhage
appearance on MRI depends on
proton content and spin properties…
3 MRI settings important in brain and spine
T1 T2 proton density
functional definition of gadolinium
non-iodinated contrast material that is hyperintense on T1 MRI
use of contrast MRI
impaired bbb
- gadolinium contrast is hyperintense on T1 MRI and does not cross normal bbb
- so tumor, infection, vascular anaomaly, normal pituitary are permeable to contrast agents and show preferential enhancement
leading cause of death in children and young adults in us
trauma
head injury is cause in 50% of deadly trauma
tf
fracture corresponds to severity of head injury
f
brain can be very injured w/o skull fx
3 types of skull fxs
- linear - nondisplaced
- depressed - displacement of skull cortexes (diploic tables) in relation to one another
- diastic - along suture line - primarily in children
define diploe
the red bone marrow between cortical ‘tables’ of the skull
define ‘growing skull fx’
aka leptomeningeal cyst
skull fx w tear of dura in kids - outpouching of brain tissue and meninges
define leptomeningeal cyst
“growing skull fx”
skull fx w tear of dura in kids - outpouching of brain tissue and meninges
pathogenesis of pneumocephalus after skull base fx
dural tear communicates w paranasal sinuses or mastoid air cells - Very low density (black) areas near paranasal sinuses
-may get csf rhinorrhea or otorrhea
feared complication of temporal bone fx
CN VII facial nerve palsy - complete ipsilateral facial paralysis
tf
facial nerve palsy causes complete ipsilateral facial paralysis
t
distal…after some nucleus… facial nerve lesion causes complete ipsi paralysis…. prior to that nucleus, lesion will only cause ipsilateral lower quadrant paralysis as opposite facial nerve cross-covers upper quadrant
epidural hematoma
- between what layers
- what blood vessels
- what % of head trauma pts
- what % of fatalities from head trauma
skull and dura
middle meningeal artery or dural venous sinus
1-4% pts w head trauma
10% of fatalities from head trauma
another word for “lentiform” hematoma
biconvex
which hematoma does not cross suture lines usually
epidural
subdural hematoma
- between what layers
- what blood vessels
- what mechanism
- what % of head injuries
dura and arachnoid maters
bridging veins
change in head velocity
10-20% of head injuries will have
chronic subdural hematoma
pres
ct appearance
elderly (brain atrophy, bridging veins stretched, easier to break w less trauma, minor trauma, or no apparent trauma at all)
- usually hypodense
- can be heterogenous if rebleeding (repeat trauma elderly) or neovascular membrane formation
acute subdural hematoma on ct
hyperdense
sometimes iso or hypodense due to csf or unclotted blood mixing w clotted blood
crescent shaped
isodense to brain after weeks and clot ages over
subarachnoid hemorrhage
- between what layers
- present in what % of head trauma cases
- CT pattern
arachnoid and pia
most moderate to severe head trauma
follows suci and/or csf cisterns at base of brain
primary brain injuries seen on imaging include…
cerebral contusion
diffuse axonal injury
brainstem (duret) hemorrhage
duret hemorrhage
brainstem hemorrhage
diffuse axonal injury (DAI)
- mechanism
- location
- ct appearance
- mri appearance
- accel decel rotation shear injury of axons
- gray-white junction, corpus callosum, dorsolateral brainstem usually
- ct is normal or shows diffuse edema
- mri is more sensitive - multiple poorly defined hyperintense areas in white matter on T2
cerebral contusion
- define
- location
- ct appearance
hemorrhage from brain impacting skull
frontal or temporal poles usually
heterogenous hyperdense areas in parenchyma on CT
how much csf do you make in a day
about 400 ml
1 common sodium problems post-op (neurosurgery)
SIADH - kidneys retain salt (euvolemic or hypervolemic)
cerebral salt wasting - kidneys dump salt (hypovolemic)
-don’t know why, can happen with various brain issues… trauma, stroke, hemorrhage, closed injury…
hydralazine class use mechanism CI precaution
-vasodilator/antihypertensive
-htn
HFrEF w intolerance to ACEI and ARB eg NYHA class III-IV african-american
-direct vasodilation of arterioles (with little effect on veins)
-Beers potentially inappropriate in 65+ pt w hx of syncope
CAD CI
mitral valve rheumatic heart disease CI
-drug-induced lupus-like syndrome (including glomerulonephritis…)
hypotension
blood dyscrasias
peripheral neuritis
pots
define
postural tachycardia syndrome
- so tachy with standing… but not always related to autonomic insufficiency like orthostatic hypotension… bp changes can be variable, not always down… various proposed etiologies unclear…
test foot for clonus
wiggle ankle to loosen then abruptly dorsiflex and hold, better if all leg relaxed so can bend knee into relaxed position too
-normal considered 0-2 beats of clonus, 3 beats or more is hyperreflexic
(neurosurg clinic)
chronic steroid toxicity similar to what disease syndrome
cushing syndrome
major side effects of chronic systemic glucocorticoid therapy
- derm and soft tissue
- eye
- cv
- gi
- renal
- gu
- bone
- muscle
- neuropsych
- endocrine
- id
- derm and soft tissue - skin thinning, purpura, cushingoid, alopecia, acne, hirsutism, striae, hypertrichosis
- eye - posterior subcapsular cataract, inc IOP, exopthalmos
- cv - arrhythmias w pulse therapy, htn, dyslipidemias, early atherosclerosis
- gi - gastritis, pud, pancreatitis, steatohepatitis, perf
- renal - hypokalemia, fluid volume shifts
- gu - amenorrhea/infertility, intrauterine growth retardation
- bone - op, avn
- muscle - myopathy
- neuropsych - euphoria, dysphoria/depression, insomnia, akathisia, mania, psychosis, pseudotumor cerebri
- endocrine - dm, hpa insufficiency
- id - opportunistic infection, inc infections, herpes zoster
(like cushing syndrome)
mechanism of adverse effects of chronic systemic steroids
those used for chronic disease (prednisone, prednisolone…) don’t have sig mineralcort, androgen, or estrogen activity, so major ae’s from HPA inhibition and iatrogenic cushing syndrome
how are steroids antiinflammatory
- inc expression of regulatory and antiinflammatory proteins
- dec expression of proinflammatory proteins
cushingoid features
body fat redistribution
-truncal obesity, buffalo hump, moon face
weight gain…
